Oncological Surgery Practice Questions

Q: A 65-year-old male presents with weight loss, cough, and hemoptysis. Imaging reveals a right upper lobe lung mass. After bronchoscopy with biopsy confirms squamous cell carcinoma, what steps should be taken for staging and treatment planning?

PET-CT and mediastinoscopy. ***PET-CT and mediastinoscopy*** - **PET-CT** is essential for detecting **distant metastases** and identifying **mediastinal lymph node involvement**, which are critical for accurate staging. - **Mediastinoscopy** provides histologic confirmation of **mediastinal lymph node metastases** (N2/N3 disease), guiding decisions regarding **surgical resectability** and the need for neoadjuvant therapies. *CT-guided biopsy and bronchoalveolar lavage* - A biopsy has already confirmed **squamous cell carcinoma**, rendering a repeat biopsy unnecessary at this stage for diagnosis. - **Bronchoalveolar lavage** primarily aids in diagnosing infections or diffuse lung diseases, and is not a standard staging tool for confirmed lung cancer. *Repeat bronchoscopy with lavage* - The initial bronchoscopy already yielded a **diagnostic biopsy**; repeating it primarily for lavage would not provide additional **staging information**. - Lavage is more useful for cytology in undiagnosed lesions or infections, not for comprehensive cancer staging after a definitive biopsy. *Chest MRI with contrast and pleural fluid analysis* - While **MRI** can provide detailed imaging of soft tissues, **PET-CT is superior** for detecting **distant metastases** and metabolically active lesions throughout the body for staging. - **Pleural fluid analysis** is indicated if a **pleural effusion** is present to check for malignant cells, but it's not a primary staging tool if no effusion is noted or for assessing distant spread or nodal involvement.

Q: Prognosis of surgery for liver secondaries is best for which cancer?

Colorectal. ***Colorectal*** - **Colorectal liver metastases (CRLM)** have the **best prognosis** after surgical resection among all liver metastases, with 5-year survival rates of **30-50%** in well-selected patients. - The liver is often the **sole site of metastasis** for a significant period, and colorectal metastases have distinct biological behavior with slower growth rates, making surgical resection a **potentially curative option**. - Established resectability criteria and multimodal treatment approaches (surgery + chemotherapy) have made CRLM one of the few metastatic cancers where long-term survival and cure are achievable. *Neuroendocrine* - While liver metastases from **neuroendocrine tumors (NETs)** are often resectable and surgery can improve symptoms and prolong survival, their prognosis is **not as favorable** as colorectal metastases. - NETs can be highly indolent or very aggressive, and the extent of liver involvement can be substantial, making complete cure less common compared to CRLM. *Genitourinary* - Liver metastases from **genitourinary cancers** (kidney, bladder, prostate) generally indicate **advanced, widely disseminated disease**, for which resection is rarely curative. - These metastases usually present in the context of **systemic disease**, and hepatic resection typically offers only palliative benefits in highly selected cases, with poor overall prognosis. *Esophageal* - **Esophageal cancer** with liver metastases represents **advanced stage disease** with very poor prognosis. - Surgical resection of esophageal cancer liver metastases is **uncommonly performed and rarely curative**, as these metastases usually signify widespread systemic disease with median survival measured in months despite treatment.

Q: What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?

Right hemicolectomy. ***Right hemicolectomy*** - Carcinoid tumors of the appendix larger than **2 cm** are considered at high risk for **lymph node metastasis** and recurrence. - A **right hemicolectomy** provides adequate margins and allows for lymph node dissection, which is essential for staging and definitive treatment in such cases. *Appendicectomy* - An **appendicectomy** alone is typically sufficient for carcinoid tumors of the appendix that are **less than 1 cm** and localized to the tip. - For larger tumors, appendicectomy carries an unacceptably high risk of **incomplete resection** and metastatic disease. *Appendicectomy + abdominal CT scan* - While an **abdominal CT scan** is useful for assessing local spread and distant metastases, it does not address the need for a more extensive surgical resection for a **large primary tumor**. - A simple **appendicectomy** in this scenario would be inadequate as definitive treatment. *Appendicectomy + 24 hrs urinary HIAA* - **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** is a biomarker used to detect and monitor **carcinoid syndrome**, which occurs in a minority of patients with carcinoid tumors. - Measuring 5-HIAA is primarily for assessing systemic symptoms rather than determining the primary surgical management of the **tumor size**.

Q: RPLND and Chemotherapy may be used in management of?

Non-seminomatous germ cell tumors of the testis. ***Non-seminomatous germ cell tumors of the testis*** - **Retroperitoneal lymph node dissection (RPLND)** and **chemotherapy** are key components in the management of non-seminomatous germ cell tumors (NSGCTs), especially for metastatic disease or after initial orchidectomy. - The combination therapy addresses both local nodal involvement (RPLND) and widespread micrometastases (chemotherapy), which are common in NSGCTs. *Non-germ cell tumors* - This is a broad category, and while some non-germ cell testicular tumors may require surgery or chemotherapy, **RPLND** is not a standard part of their management in the same way it is for germ cell tumors. - The specific treatment depends on the tumor type (e.g., Leydig cell tumor, Sertoli cell tumor), stage, and histology, and often involves less aggressive approaches. *Seminomatous germ cell tumors* - **Seminomas** are highly radiosensitive and often respond well to **radiation therapy**, particularly for localized disease or retroperitoneal nodal involvement. - While chemotherapy is used for metastatic seminoma, **RPLND** is generally not indicated for seminomas due to their radiosensitivity and different metastatic patterns compared to NSGCTs. *Lymphoma of the testis* - Testicular lymphoma is a type of **non-Hodgkin lymphoma** and is primarily managed with systemic **chemotherapy** (e.g., R-CHOP) and sometimes radiation therapy. - **RPLND** is not a standard treatment modality for testicular lymphoma, as it is a systemic disease requiring systemic treatment, not local surgical excision of retroperitoneal nodes.

Q: What is the primary treatment for early-stage non-small cell lung cancer?

Surgical resection. ***Surgical resection*** - **Surgical resection** (lobectomy or segmentectomy with lymph node dissection) is the **primary and definitive treatment** for early-stage non-small cell lung cancer (Stage I-II). - For **Stage IA disease**, surgery alone provides excellent outcomes with 5-year survival rates of 70-90%, and adjuvant chemotherapy is generally **not indicated**. - For **Stage IB-II**, surgery remains primary, with adjuvant chemotherapy considered selectively based on tumor size (>4 cm), poor differentiation, vascular invasion, or other high-risk features. - Complete surgical resection offers the **best chance of cure** for resectable early-stage NSCLC. *Surgical resection with adjuvant chemotherapy* - While this combination is important for **select early-stage cases** (high-risk Stage IB, Stage II-IIIA), it is **not the universal primary treatment** for all early-stage disease. - Adjuvant chemotherapy is an **addition** to surgery in specific scenarios, not part of the primary treatment for the majority of early-stage (especially Stage IA) patients. - Current guidelines recommend risk stratification before adding adjuvant therapy. *Radiotherapy* - **Radiotherapy** (stereotactic body radiotherapy/SBRT) is reserved for **medically inoperable** patients or those who refuse surgery. - It is not the primary treatment when the patient is a **surgical candidate**. - May be used as adjuvant therapy in patients with positive margins or N2 disease. *Immunotherapy* - **Immunotherapy** has emerging roles in neoadjuvant/adjuvant settings for resectable NSCLC (recent trials showing benefit). - However, it is **not established as primary monotherapy** for early resectable disease. - More commonly used in advanced/metastatic NSCLC or as part of combination regimens in clinical trial settings for early disease.

Q: What is the treatment of choice in desmoid tumors?

Wide excision. ***Wide excision*** - For **desmoid tumors**, **complete surgical resection with clear margins** is the primary treatment of choice due to their infiltrative nature and high recurrence rates. - This approach aims to minimize local recurrence and prevent tumor progression, which can impact adjacent structures. *Irradiation* - **Radiation therapy** is typically reserved as an **adjuvant** treatment after surgery or for unresectable tumors, not as a primary standalone treatment. - While it can help reduce recurrence rates, it carries risks of **secondary malignancies** and local tissue damage. *Local excision* - **Local excision** alone is insufficient for desmoid tumors due to their **infiltrative growth pattern** and high propensity for **local recurrence** if positive margins remain. - It often leads to incomplete removal, necessitating further intervention and increasing the risk of tumor progression. *Local excision following radiation* - Combining local excision with initial radiation is not the preferred sequence; **wide surgical excision** is typically performed first. - Radiation might be considered preoperatively in specific cases to **reduce tumor size** or postoperatively for **positive margins**, but starting with local excision after initial radiation is not the standard primary management.

Q: In which of the following cancers is intraoperative radiotherapy (IORT) applicable?

All of the options. ***All of the options*** - **Intraoperative radiotherapy (IORT)** is applicable to all three cancers listed: gastric cancer, colon carcinoma, and pancreatic carcinoma. - IORT is a technique where a **single, high dose of radiation** is delivered to the tumor bed during surgery to improve local control and reduce late toxicity to surrounding healthy tissues. - All three cancers benefit from IORT due to their **high risk of local recurrence** and the ability to directly target the tumor bed while sparing adjacent critical organs. **Gastric cancer:** - IORT addresses **high rates of local recurrence** after conventional surgery, especially in locally advanced stages - Allows direct radiation of potentially involved regional lymph nodes or margins difficult to eradicate surgically - Particularly useful when complete surgical clearance carries excessive morbidity risk **Colon carcinoma:** - IORT considered in **locally advanced or recurrent disease**, particularly when tumors invade adjacent structures - Beneficial after resections with positive or close margins - Delivers high dose to microscopic residual disease in the tumor bed, avoiding damage to vital organs from external beam radiotherapy **Pancreatic carcinoma:** - High propensity for **local invasion and recurrence** makes IORT particularly relevant - Delivers high dose directly to tumor bed following resection when microscopic residual disease is suspected - Overcomes limitations of external beam radiation due to proximity of critical organs (duodenum, stomach, kidneys)

Q: Primary treatment for localized malignant melanoma is

Wide excision. ***Wide excision*** - This is the **primary treatment** for localized malignant melanoma, aiming to completely remove the tumor along with a surrounding margin of healthy tissue to reduce recurrence risk. - The excisional margin width depends on the **Breslow depth** (tumor thickness). *Radiotherapy* - Not the primary treatment for localized melanoma, as melanoma cells are often **radioresistant**. - It may be used as **adjuvant therapy** for local control in cases of positive margins or nodal involvement, or for palliative care in metastatic disease. *Excision* - While excision is part of the treatment, the term **"wide excision"** specifically implies removing a sufficient margin of healthy tissue around the tumor. - Simple excision without appropriate margins is generally inadequate for malignant melanoma and carries a **high risk of local recurrence**. *Chemotherapy* - It is generally **not the first-line treatment** for localized melanoma due to limited efficacy and significant side effects. - Chemotherapy agents are typically reserved for **advanced or metastatic melanoma** and are often replaced by targeted therapies or immunotherapy in modern practice.

Question 1

What is the most effective treatment strategy for a young adult with newly diagnosed glioblastoma, based on current evidence?

Accepted Answer

Surgical resection followed by adjuvant radiation and chemotherapy, tailored by molecular profiling.

Answer

Surgical resection only, as it is the primary treatment.

Answer

Radiation therapy alone, to maximize quality of life.

Answer

Participation in clinical trials for experimental therapies only.

Question 2

A 65-year-old male presents with weight loss, cough, and hemoptysis. Imaging reveals a right upper lobe lung mass. After bronchoscopy with biopsy confirms squamous cell carcinoma, what steps should be taken for staging and treatment planning?

Accepted Answer

PET-CT and mediastinoscopy

Answer

CT-guided biopsy and bronchoalveolar lavage

Answer

Repeat bronchoscopy with lavage

Answer

Chest MRI with contrast and pleural fluid analysis

Question 3

What should be the plan of management for a patient in whom T2 gall bladder carcinoma is discovered during a simple cholecystectomy?

Accepted Answer

Resection of 4b-5 segment, dissection of the N1-2 nodes and excision of port sites

Answer

Post operative adjuvant chemotherapy

Answer

Whipple procedure

Answer

Consideration of radical cholecystectomy based on specific case factors.

Question 4

Prognosis of surgery for liver secondaries is best for which cancer?

Accepted Answer

Colorectal

Answer

Neuroendocrine

Answer

Esophageal

Answer

Genitourinary

Question 5

What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?

Accepted Answer

Right hemicolectomy

Answer

Appendicectomy

Answer

Appendicectomy + abdominal CT scan

Answer

Appendicectomy + 24 hrs urinary HIAA

Question 6

RPLND and Chemotherapy may be used in management of?

Accepted Answer

Non-seminomatous germ cell tumors of the testis

Answer

Non-germ cell tumors

Answer

Seminomatous germ cell tumors

Answer

Lymphoma of the testis

Question 7

What is the primary treatment for early-stage non-small cell lung cancer?

Accepted Answer

Surgical resection

Answer

Radiotherapy

Answer

Surgical resection with adjuvant chemotherapy

Answer

Immunotherapy

Question 8

What is the treatment of choice in desmoid tumors?

Accepted Answer

Wide excision

Answer

Irradiation

Answer

Local excision

Answer

Local excision following radiation

Question 9

In which of the following cancers is intraoperative radiotherapy (IORT) applicable?

Accepted Answer

All of the options

Answer

Gastric cancer

Answer

Colon carcinoma

Answer

Pancreatic carcinoma

Question 10

Primary treatment for localized malignant melanoma is

Accepted Answer

Wide excision

Answer

Radiotherapy

Answer

Excision

Answer

Chemotherapy

Oncological Surgery — MCQs

Oncological Surgery — MCQs

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